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Executive Functions: Low Tech and High Tech Remediation StrategiesPresented By: Gina England MA, CCC-SLPSpeech and Language Pathologistgeseminars@ It has been said that executive cognitive functions are what differentiate human beings from animals.How then, do we explain the spider’s ability to craft a web that is both beautiful and essential to its survival?How then, does a black lab know exactly where the “treats” are stored in the kitchen?How then, did a cat know to use its claws to open a sliding screen door?How then, did an aging dog know that if he needed to pee in the garage, he should do it directly over the floor drain?Regardless of our species, executive cognitive functions are those skills that make it possible for us to thrive, survive and define “alive” as one’s desire to live their life safely, meaningfully and independently.Or maybe I just have had really smart pets….Despite what you see in the above illustration, the brain cannot be viewed as separate pieces. Executive cognitive functions do not exclusively live in the frontal lobes. The process of cognition “pulls” information from all areas of the brain through the intricate relay stations of our sub-cortical structures.Considerations In the Selection of Low Tech versus High Tech Remediation Strategies – One Size Does Not Fit All!1. The age of the individual – new learning becomes progressively more challenging as we age2. Sensory impairments – hearing and/or vision loss3. Physical challenges of the upper extremities4. Initiative or motivation5. Available community supports6. Knowledge/experience/comfort with electronic devices – FAT CAT Assessment for hi-tech capability7. Identification of premorbid use of compensatory strategies – let’s not reinvent the wheel8. What Needs to be Managed – A Needs AssessmentMaking/keeping appointmentsWork or school scheduleWork or school task/assignmentsSocial activitiesMedication managementActivities of daily living – groceries/laundryChild careDriving directionsHousehold financial managementBill PayingKeeping track of personal effects (keys, phone, wallet, hearing aids, glasses, name tag)Names of peopleSpecial occasionsConversations with peopleTelephone messages on an answering machineTelephone numbersEmail addressesI am your best example:Android smartphoneiPadDesk top personal computerLaptopWeekly planner bookTo do listsPost it notesStrategies must be individual specificStrategies may very well be a combination of both low and hi techFactors That Facilitate Successful Training:Include the individual in strategy selectionChoose strategies that are concrete and functional in nature; easy to learnIntroduce compensation at a Rancho Level 5-6Relate each strategy to a specific deficit areaAssure the chosen strategy is age appropriateGive the strategy a name that is easily recalled and iconic to its natureSelect strategies that might impact multiple executive functions at the same timeHealthy Lifestyle – sleep, diet, hydration, exerciseFamilial and/or community supportsConsideration of the patient’s personal history, cultural background, personality, pre-morbid intellect and level of formal educationThe Stages of Strategy Training: (Sohlberg and Mateer 2001)1. Acquisition: to learn the names, purpose and use of any strategy2. Application: to utilize the strategy during functional tasks in the clinic3. Adaptation: to utilize the strategy in community based settingsThe Ongoing Debate: Online Cognitive Training vs. Compensatory Strategy TrainingNeuro-stimulation vs. Neuro-activationThe concept of Neurobics as it relates to NeuroplasticityDisparity in evidence based researchPassive (rote) demands vs active demands for critical thinkingWhat a PET SCAN can tell us about NeurobicsThe Primary Goals of Rehabilitation:1. To empower the individual to regain the highest level of functioning and independence2. An individualized treatment plan for individual centered care3. To include the patient and their families as an integral component of the rehab team4. To teach new ways to compensate for abilities that may be forever altered or lost5. To select compensatory strategies that are realistic, easy to employ and result in a desired effectReview: The Cognitive Retraining PyramidA. Attention TrainingLow Tech > Table Top Activities:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hi Tech > Software/Apps:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________B. Memory TrainingThe Neuroanatomy of Memory:Right frontal lobe – working memory and short term memoryRight temporal lobe – visual recall deficitsLeft temporal lobe – verbal recall deficitsThalamus - ? the organizer of memoriesHippocampus - ? long term memoriesAmygdala - emotional memoryMemory as a 3 Step Process:1. Taking Information In:Awake/aware/alertConcentrate/focusUnderstand/comprehendSignificance/importance2. Storing the Information:OrganizeStrategy useRehearsalEncoding – reducing information to key points3. Retrieving the Information on Demand:SearchAccessLow Tech Memory Strategies:Daily planner for appointments; including a journal section for note takingKeep paper and pencil next to a landline phoneWall Calendar for appointments; color code type of appointmentVisual checklistsTo do listsCheat sheets for sequencing of multi-step tasksPost-It notesReiteration/clarificationName associationsA set/unchangeable location for personal effects – brain centralPost important alerts where they can be easily seenAn alphabet searchChaining/chunkingKey word listeningThe Detective – who/what/where/when/why/howHi Tech Memory Strategies:The native functions of a smartphone/tablet: notes, calendar, alerts, alarms, GPS,email, video recording, voice mail, text messaging, cameraFunctional use of a smartphone during therapy as the modality to address memoryMemory Apps:Forgetful (video, audio and text reminders)NotifyCalAlarm ($) (alarmed calendar)NudgeVoCal ($) (alerts are given in the user’s own voice)It’s Done ($) (keeps track of completed tasks)iReminder ($)Microcassette recorderWatch alarmAnswering machineAuto GPS systemsCooking timerAlarm clockC. Organization TrainingLow Tech Organizational Strategies:Set up a personal workspace – strong organizational practices will reduce the demand on memoryDevelop a filing systemLabel storage bins, drawers, boxes with their contentsKeep frequently used personal items in a central VISIBLE locationDry erase boardsRefrigerator magnets – out of sight, out of mindWeekly pill boxPersonal information cardMedication/medical history sheetSelf talk – talk through a plan; does it sound feasibleDeclutter living and work spaces – distractions diminish memory functionsGet a good night’s sleep!Daily/weekly/monthly plannerPhone/address bookBill file – bills/to be paid/ready to fileVisual graphic organizersColor code tasks – low(yellow), medium(orange), high(red) priorityHi Tech Organizational Strategies:Smart Phone/tablet therapy – using native functions for basic organizational tasksOrganizational Apps:Scheduler (pictures, video or audio prompts)Due ($) (set timers for individual tasksPriority Matrix ($) (color coded organization)Wunderlist (to do and task lists)Popplet ($) (graphic organization of a complex task)iStudiez Pro ($) (calendar-assignments-planner)index Card ($) (allows you to work on a task in small manageable chunks)Visual Schedule Planner ($) Dragon Dictation (verbally input notes instead of typing them)EvernoteD. Putting It All TogetherIntroduction to Cognitive Simulation Therapy:Professional literature for the field of speech pathology contains occasional references to “simulation therapy” or “simulated/virtual activities” within the context of therapeutic modalities relative to cognitive rehabilitation. The literature substantiates the need for a more functional approach to neuro-rehabilitation if we are to realize optimal functional outcomes in our current healthcare climate. This is especially relevant today as clinicians deal with reduced lengths of stay and limited outpatient benefits in their daily clinical practice. The incorporation of readily available and free websites into the cognitive therapy session is one way to achieve our mutual goal of optimal functional outcomes. Case Studies Utilizing Low Tech Interventions:1. “LISA”DIAGNOSIS: TBIIMPAIRMENTS: POOR INITIATION OF DAILY ACTIVITIES, DISORGANIZATIONSTRATEGY NAME: MY LIFE COACHSTRATEGY DESCRIPTION: DESIGNATING A SPECIFIC PERSON THAT LISA WAS ACCOUNTABLE TO FOR COMPLETION OF CHORES, ASSIGNMENTS, APPOINTMENTS ETC2. “LAURA”DIAGNOSIS: SEVERE TBIIMPAIRMENTS: TOTALLY AMNESTIC/SEVERE DISORIENTATIONSTRATEGY NAME: MY TIMELINESTRATEGY DESCRIPTION: CREATED A BIOGRAPHY SECTION IN HER DAY PLANNER WHICH OUTLINED SIGNIFICANT EVENTS IN HER LIFE, CHRONOLOGICALLY. EACH ENTRY HAD AN ACCOMPANYING PHOTOGRAPH TO HELP ILLUSTRATE THE EVENT.3. “ROLAND”DIAGNOSIS: ANOXIC BRAIN INJURY, CARDIAC ARRESTIMPAIRMENTS: SEVERELY IMPAIRED SHORT TERM MEMORYSTRATEGY NAME: FUDGINGSTRATEGY DESCRIPTION: HE WAS A WELL KNOWN FIGURE IN HIS COMMUNITY WHO WAS DEEPLY CONCERNED OVER HIS INABILITY TO REMEMBER THE NAMES OF PEOPLE IN HIS TOWN (A PREVIOUS STRENGTH AND POINT OF PRIDE). HE WAS TAUGHT TO “FUDGE IT” BY NOT TRYING TO GREET SOMEONE BY NAME, BUT TO GREET THEM WITH A SNIPPET OF SHARED PERSONAL HISTORY INSTEAD4. “DIMITRI”DIAGNOSIS: RIGHT FRONTAL LOBE ANEURYSM/HEMMORHAGEIMPAIRMENTS: IMPULSIVITY RESULTING IN IMPAIRED SOCIAL PRAGMATICS INCLUDING FREQUENT INTERRUPTIONS WHEN OTHERS WERE SPEAKING AND A “JUMP THE GUN” RESPONSE PATTERNSTRATEGY NAME: CHIN STROKE AND POCKET PADSTRATEGY DESCRIPTION: STROKING HIS CHIN FIT HIS PERSONALITY. HE APPEARED TO BE CONTEMPLATING A RESPONSE BUT IN ACTUALITY HE WAS WAITING FOR THE SPEAKER TO FINISH A THOUGHT. HIS FREQUENT INTERRUPTIONS OCCURRED BECAUSE HE WAS AFRAID HE WOULD FORGET WHAT HE WANTED TO SAY. THE SMALL NOTEPAD/PENCIL IN HIS POCKET ALLOWED HIM TO WRITE DOWN KEY WORDS UNTIL IT WAS HIS TURN TO SPEAKCase Studies Utilizing Hi Tech Interventions:1. “MATT”DIAGNOSIS: ANOXIC BRAIN INJURY, DRUG OVERDOSEIMPAIRMENTS: PROFOUNDLY IMPAIRED SHORT TERM MEMORYSTRATEGY NAME: THE BROOKSTONE CLOCKSTRATEGY DESCRIPTION: A CLOCK WAS FOUND AT BROOKSTONE THAT COULD BE PROGRAMMED ON THE HOUR TO PRODUCE AN AUDIBLE VERBAL REMINDER. THE SURVIVOR WAS ACTIVELY INVOLVED IN THE SELECTION OF MESSAGES AND AT WHAT HOUR OF THE DAY THEY WOULD BE HEARD.2. “SHEA”DIAGNOSIS: TRAUMATIC BRAIN INJURYIMPAIRMENTS: SEVERELY IMPAIRED SHORT TERM MEMORY, DYSGRAPHIA, SPASTICITYSTRATEGY NAME: THE RECORDERSTRATEGY DESCRIPTION: THE PATIENT USED A MICROCASSETTE RECORDER TO REMIND HIMSELF OF TASKS THAT HE WANTED TO DO IN HIS NEXT ENVIRONMENT (HOME, REHAB, DOCTOR APPT.)3. “DELLA”DIAGNOSIS: CEREBRAL ANEURYSMIMPAIRMENTS: SEVERE SHORT TERM MEMORY IMPAIRMENT, DISORGANIZATIONSTRATEGY NAME: SMART AND SASSY (HER SMART PHONE)STRATEGY DESCRIPTION: ONE BY ONE I TAUGHT HER HOW TO USE THE NATIVE FUNCTIONS ON HER I-PHONE (WHICH SHE HAD PREVIOUSLY ONLY USED TO MAKE TELEPHONE CALLS). WE BEGAN WITH NOTE TAKING AND THEN PROCEEDED TO TEXT MESSAGING, TAKING PHOTOS, ORGANIZING PHOTOS INTO ALBUMS AND LASTLY, THE USE OF A DIGITAL CALENDAR FOR HER APPOINTMENTS AND IMPORTANT FAMILY DATES4. “MARY”DIAGNOSIS: RIGHT HEMISPHERIC STROKEIMPAIRMENTS: IMPULSIVITY, DISORGANIZATION, POOR FOCUSED ATTENTIONSTRATEGY NAME: TEXT 4 MESTRATEGY DESCRIPTION: WE NEEDED SOMETHING THAT WAS SHORT, SWEET AND FAST DUE TO HER VERY LIMITED FOCUSED ATTENTION. SHE LOVED TO SEND PEOPLE TEXT MESSAGES SO WE USED THIS AS A WAY FOR HER TO REMEMBER THINGS THAT NEEDED TO BE DONE BY THE END OF THE DAY. SHE DID THIS WHILE AT HOME AND DURING OUTPATIENT REHAB.One Last Resource………….American Congress of Rehabilitation Medicine (ACRM):Cognitive Rehabilitation Manual: Translating Evidenced-Based Recommendations into Practice150 pages including clinical formsTargets impairments of executive functions, memory, attention, hemi-spatial neglect and social communicationOnline price through ACRM directly is $ 125.00 for non-membersPreview the table of contents at: publications/cognitive-rehab-manual/The interventions described can be readily used by speech pathologists, occupational therapists, psychologists and other rehabilitation professionalsA great team resource Bibliography:Altschuler, Eric, Multari, Alicia et.al. “Situational Therapy for Wernicke’s Aphasia”. Medical Hypotheses; (2006) 67, 713-716.Bergquist, T. Gehl, C. Mandrekar, J. et al. (2009). “The Effect of Internet-BasedCognitive Rehabilitation in Persons With Memory Impairments After SevereTraumatic Brain Injury”. Brain Injury, 23, 790-799.Cicerone, Keith, Levin, Harvey et.al. “Cognitive Rehabilitation Interventions for Executive Function: Moving From Bench to Bedside in Patients With Traumatic Brain Injury”. Journal of Cognitive Neuroscience; (2006) 18:7, 1212-1222.Culley?C , Evans?JJ. (2010) “SMS Text Messaging as a Means of Increasing Recall of Therapy Goals In Brain Injury Rehabilitation: A Single-Blind Within-Subjects Trial”. NeuropsychologyRehabilitation. 20: 103-119.Hagen, Chris (1997). Rancho Los Amigo’s Scale of Cognitive Functions – Revised.Healthsource Saginaw: “Speech Language Pathology Memory Training”. Online Article. , Lawrence C. and Rubin, Manning (1999). Keep Your Brain Alive: 83 Neurobic Exercises. New York: Workman Publishing CompanyKennedy, M.R. Coelho, C. Turkstra, L. (2008). Interventions for Executive Functions After Traumatic Brain Injury: A Systematic Review, Meta-analysis and Clinical Recommendations”. Neuropsychology Rehabilitation 18(3) 464-486.Kim, Scott (2010). “Neurobics: Flexible Thinking”. Neurology Now. 6 (4) 11-15Klinger, E.,Kadri, A. et.al. “AGATHE: A Tool for Personalized Rehabilitation of Cognitive Functions Based on Simulated Activities of Daily Living”. IRBM; Volume 34, Issue 2, 113-118.Mueller and Dollaghan (June 2013). “ Executive Function Assessment”. Journal of Speech,Language and Hearing Research. Vol 56 pp. 1051-1064Satish, U., Streufert, S., Eslinger, PJ. “Simulation-based Executive Cognitive Assessment and Rehabilitation After Traumatic Frontal Lobe Injury: A Case Report”. Disability and Rehabilitation; (2008); 30(6), 486-478.Tristani,M. and Riquelme, L.F. (July 2015). “The tri-fold risk of malnutrition, dehydration and dysphagia in persons with Dementia: An assessment and management protocol”. Presentation at the annual meeting of the Alzheimer’s Association International Conference, Washington DC.Zhang, Ling et.al. “A Virtual Reality Environment for Evaluation of a Daily Living Skill in Brain Injury Rehabilitation: Reliability and Validity”. Archives of Physical Medicine Rehabilitation; (2003); 84: 1118-1124.Zickefosse, Hux, Brown and Wolf (2013). “Let the Games Begin: A PreliminaryStudy Using Attention Process Training-3 and Lumosity Brain Games to RemediateAttention Deficits Following TBI”. Brain Injury Vol. 27 (6) pp. 707-716 ................
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